OBJECTIVE:
To determine the prevalence of the heavy use of drugs among elementary and
high school students in a sample of public and private schools, and to identify
associated demographic, psychological, cultural and social factors.METHODS: This report describes a cross-sectional study using an intention-type
sampling technique that compared public schools in central and peripheral areas
and private schools. An anonymous self-administered questionnaire was applied.
The sample consisted of 2,287 elementary and high school students in the city
of Campinas in 1998. Heavy use of drugs was defined as the use of drugs on 20
or more days during the 30 days preceding the survey (WHO, 1981). For the statistical
analysis, polytomic logistic regression analysis (logit model) was utilized
to identify factors that influenced this manner of using drugs.RESULTS: Heavy use of legal and illegal drugs was found as follows: alcohol
(11.9%), tobacco (11.7%), marijuana (4.4%), solvents (1.8%), cocaine (1.4%),
medications (1.1%) and ecstasy (0.7%). The heavy use of drugs was greatest among
students at the city-center public school who had daytime jobs and studied in
the evenings. These students were in the A and B socioeconomic classes and had
had little religious education during childhood.CONCLUSIONS: Greater availability of cash and specific socialization
patterns were identified as factors associated with the heavy use of drugs among
students.

An individual's
first experiences with drugs often take place during adolescence. During this
phase, the individual is particularly vulnerable from a psychological and social
point of view. Thus, it is particularly important to study this age group in
detail, especially in relation to frequent and heavy use of legal and illegal
drugs, and to identify the psychological and sociocultural factors that are
associated with such use.10

At the request
of the Ministry of Health, a group of researchers made four extensive surveys
on drug use, covering ten Brazilian state capitals, in the years 1987, 1989,
1993 and 1997.4 Comparison of these four surveys showed that the
drugs that were most utilized were alcohol, tobacco and solvents. The surveys
also revealed that heavy use of marijuana was increasing in these ten state
capitals, as was the use of alcohol in eight of them.

Several
national and international studies have analyzed the associations of psychological
and sociocultural factors with drug use among students. They have, for example,
identified that variables like male gender,3 age,10,16
work,17 family breakup9 and absence of religion8
are associated with greater use of drugs among students, in a diversity of sociocultural
contexts.

In view
of this, accurate knowledge of the factors associated with drug use among young
people in Brazil has great relevance, since it would allow interventions to
be undertaken in relation to behavior and risk factors, with the aim of inhibiting
the possible progression to heavy use of legal and illegal drugs, which are
progressively addictive and deleterious for the individual.

Previous
Brazilian studies on drug use among students have generally been conducted in
the state capitals. The present study has also compared different types of schools:
central and peripheral public schools, and private schools. It is very plausible
that the reality of drug use in different areas of a city may vary, thus revealing
epidemiological unevenness within the urban environment.

It might
therefore be presupposed that, in the peripheral regions of the large Brazilian
cities, where there is a higher death rate due to violence and drug trafficking,
would also have higher drug consumption. The present work had the objective
of determining the prevalence of heavy drug use among elementary and high school
students in central and peripheral public schools and private schools, and the
sociodemographic, cultural and psychopathological factors that are associated
with such use

METHODS

This was
a cross-sectional study using an intention-type sampling technique that focused
on studying three distinct types of school in the city of Campinas, State of
São Paulo: city-center public schools, peripheral public schools and
private schools. The objective of this was to identify differences in the pattern
of alcohol and drug use in distinct areas of the city. The general methodological
lines followed were those proposed by the Brazilian Center for Information on
Psychotropic Drugs (Centro Brasileiro de Informações sobre
Drogas Psicotrópicas  CEBRID), with the adaptations needed because
of the objectives and size of the study.2

An anonymous
self-administered questionnaire based on the CEBRID questionnaire was utilized.
In accordance with the procedure standardized and recommended by CEBRID, it
was applied collectively, in the classroom, without the presence of the teacher.
A clear and detailed explanation of the research objectives was given to the
students, with an emphatic guarantee of the anonymous and confidential nature
of the questionnaire. Doubts regarding the questions were clarified and the
questionnaires were gathered in after around 50 minutes. The sample size was
calculated using the Epi Info software, from a pilot study. This sample size
calculation was done by estimating 5% of the type I (alpha) error with a finite
population estimated to be 100,000 students in the city, at the schooling levels
being studied, without replacement; drug user prevalence of 1%; and design errors
of no more than 1%, with delta precision of 1%.

Since the
objective was to compare substantial differences in behavior between public
schools in central and peripheral locations and private schools, for each schooling
level, a minimum sample of 367 elementary and 367 high school students for each
of the three intended school types became necessary. Thus six sets of 400 students
were formed, totaling 2,400 students. The elementary school students were drawn
from the sixth and eighth grades, and the high school students from the first
and third years of high school.

From the
school lists supplied by the education authorities, an intentional choice of
participants was made. Two city-center public schools, two peripheral public
schools and three private schools were selected that all catered for elementary
and high school education. From the lists of students and classes of 35 students,
six classes were drawn by lots from each school year, per school. All the students
present were invited to fill out the questionnaires. During the survey, no irregularity
in student attendance was noted in the classrooms visited. All students who
answered the questionnaire were included, and 86 students aged over 26 years
were then excluded, since they were over the age limit for the study.

A total
of 2,375 questionnaires were applied. No student refused to answer it. Two questionnaires
were rejected because they were incompletely filled in or the questions had
not been understood.

Consequently,
the sample consisted of 2,287 students from the elementary and high school levels
of central and peripheral public schools and private schools in the city of
Campinas, State of São Paulo, in the year 1998. The official estimates
for the number of students enrolled in the city at that time indicated that
there were around 56,000 students in the sixth to eight grades of elementary
school and 52,000 in high school. Thus, the sample studied represented approximately
2% of the student total.

Heavy use
of drugs was defined in accordance with the World Health Organization (1981)
definition,18 as the use of drugs on 20 or more days during the 30
days preceding the survey.

To identify
the factors that influenced the use of drugs, logistic regression analysis (logit
model) was utilized.

The drugs
studied were alcohol, tobacco, non-prescription psychotropic medications, marijuana,
cocaine and ecstasy. The regressive variables were the type of school (peripheral
public, central public or private); level of schooling; period of the day when
students studied; gender; socioeconomic class; work; preferred type of leisure
activities; parents' marital situation; who students lived with; who students
had been brought up by over the last two years; whether students felt supported
and understood by their parents; whether they felt supported and understood
by their friends and/or girlfriend/boyfriend; whether they had a religion; religious
affiliation; religious education during childhood; and the GHQ12 (General
Health Questionnaire 12), which assesses minor psychiatric symptoms like
anxiety, depression and insomnia and was validated in Brazil by Mari & Willians,7
1985.

Since the
use of several drugs (multiuse) is known to be frequent and, with the aim of
comparing students who did not use any drug during that month with those who
made heavy use, a variable called DRUG was created for the present study, which
assumes a value of 0 if the student did not make use of any of the drugs
cited in the study during the past month, and 1 if he or she makes use
of at least one drug on 20 days or more of the past month (heavy use of at least
one of the drugs cited in the study). Heavy use of legal and illegal drugs
is generally the type of use that precedes chemical dependence and all its medical,
psychological and social-familial consequences.13

The multivariate
logistic regression estimates for heavy use of drugs are presented in Table
2.

The probability
of heavy use of drugs was greater among the students of the city-center public
schools who had daytime jobs and studied in the evenings. These students were
in socioeconomic classes A and B and had had little religious education during
childhood.

The probability
that students at the city-center public schools would make heavy use of drugs
was 4.0 times greater than for those in the peripheral schools. For students
who worked, it was 2.5 times greater than for those who did not work. For students
who studied in the evenings, it was 2.2 times greater than for those who studied
in the mornings. For socioeconomic classes A and B, it was 2.0 times greater
than for those in classes D and E. For those who had had little religious education
during childhood, it was 1.7 times greater than for those who had had a very
religious education. For those who felt they had little support and understanding
from their families, it was 1.2 times greater than for those who felt they had
a lot of support and understanding from their families. Every additional point
on the GHQ-12 scale increased the chance of the student making heavy use of
drugs by 1.2 times.

DISCUSSION

Several
authors have reported that, for research that has the aim of identifying the
prevalence of drug use among students, the method most commonly utilized is
the self-administered questionnaire applied collectively in the classroom.11
This choice is justified by its relative cheapness and high acceptance among
the individuals surveyed, since that the refusal rate is less than 1%. This
is considered to be a good procedure for obtaining information regarding private
behavior, because anonymity is explicitly guaranteed.12

However,
it must be stressed that the type of questionnaire utilized in the present work
measures reports of drug consumption and not the consumption in itself. Caution
is therefore needed in the interpretation of the data.2

Another
limitation of this research design is that, because it is a survey done in the
classroom, the young people with more serious involvement with drugs may have
already been excluded from the school system, or they may be very frequently
absent, and thus may not have been picked out by this study. Studies designed
specifically to evaluate the subpopulation that has abandoned or has been expelled
from elementary and high schools will be needed to verify this hypothesis.

The sample
was not representative of the public and private schools of Campinas, which
impedes the extrapolation of the data.

The different
drugs utilized

The single
drug most utilized heavily in the present study was alcohol (11.9%), closely
followed by tobacco (11.7%). Their high prevalence of around 12% indicates that
such use is relevant and preoccupying, and must be taken into account in relation
to possible educational, preventive and therapeutic actions aimed at young people
at school.

The illegal
drug most utilized in the present study was marijuana (4.4% made heavy use of
marijuana). Swadi16 (1988), in London, and also Stevens et al15
(1995), in New Hampshire (USA), also detected that the illegal drug most utilized
in these contexts was marijuana. In the 1997 survey performed by CEBRID in ten
Brazilian state capitals, marijuana use only exceeded solvent use as the drug
of greatest lifetime use in the city of Porto Alegre. In the other state capitals,
it appeared in second or third position (after solvents and ansiolitics). Comparison
of the four CEBRID surveys has shown that frequent and heavy use of marijuana
presented statistically significant growth.4 Marijuana is considered
by many young people (and sometimes their families) to be a soft drug, and perhaps
for this reason more acceptable. There is evidence, however, that heavy
use of the drug has serious implications for the physical and mental health
of its users.14

Solvents
appear just behind marijuana. It is important to remember that these are drugs
with great potential for harm to health, due principally to their neurotoxicity.4

Differing
from the research by Muza10 (1997), cocaine appeared in the present
study ahead of psychotropic medications, occupying the third place among the
illegal drugs. Data from the four surveys by CEBRID show that frequent use of
cocaine has increased in the state capitals surveyed. Statistical indicators
such as hospital internments and seizures of cocaine by the Federal Police also
show the growth in the use of this drug.4 Particularly worrying is
the growing use of cocaine in the form of crack, because such use implies the
rapid development of dependence,5,6 involvement in criminal activities6
and triggering of serious psychiatric conditions.5

Ecstasy
was the least-used drug, perhaps because it is expensive and still not widely
disseminated in the city of the present study, as well as being strictly linked
to a specific subculture (dance) and its rituals, such as rave parties.1

Sociocultural
variables associated with the heavy use of drugs

At present,
most researchers consider that the use of drugs among students is not caused
by a single factor, but by a combination of several of them, such as genetic,
psychological, familial, socioeconomic and cultural factors. Thus, it is understood
that the use of and dependence on drugs are very complex phenomena that cannot
be reduced to one facet of a biological, psychological or social nature.

In the present
study, through the multivariate analysis of the data, it was observed that,
contrary to what was expected, the use of drugs was lower among students in
the peripheral public schools. These are areas of the city where it is thought
that there is more drug trafficking, which is supposed because of the higher
death rate from violent causes and the seizures of drugs made by the police.
Despite the supposed greater drug trafficking in these neighborhoods, the consumption
of drugs among the students who attend the schools of the periphery is significantly
lower than for those in the central neighborhoods.

In this
sense, it is plausible that financial wherewithal may exercise a significant
influence, since in the present study it was found that, in addition to being
associated with working, the heavy use of drugs was associated with belonging
to socioeconomic classes A and B. Thus, the students at peripheral public schools,
despite living in areas of the city where drug trafficking is supposedly more
intense, have less purchasing power for buying such drugs. Another possibility
is that the young people of these neighborhoods who are involved with the heavy
use of drugs end up being expelled from the school system with a certain frequency,
and perhaps get involved in small-scale drug trafficking, including for enabling
their own consumption.

The data
from the present research also corroborates other studies that show the relationship
between greater use of drugs and students who work.16 The results
obtained in relation to work, and those in the literature, give pause for thought
regarding some relatively well established beliefs within Brazilian society,
such as the idea that free time is a factor that favors the use of drugs. Such
a concept would imply the identification of a supposed poor student who would
spend most of his free time on the streets and thus would be vulnerable to the
use of drugs. For this reason, reflection in relation to working adolescents
needs to be refocused from doing work versus not doing work, to how the work
is done, or in other words, there needs to be analysis of the quality of the
impact of different types of work on young people.

It is possible
to raise a hypothesis that the association between heavy use of drugs and work
found in the present study may have occurred because of at least three factors:
the stress consequent to taking on an adult function at an early age that is
full of obligations; the financial wherewithal resulting from receiving a salary;
and also socialization patterns associated with the "world of work" (for example,
drinking at the end of the working day).

A significant
religious dimension was also revealed in the present study. Students who had
greater religious education during childhood were shown through the multivariate
analysis to have significantly less heavy use of drugs. The literature generally
shows that young people with some sort of connection to religion make less use
of drugs.8,11

Such an
association may be related to the moral codes implicit in religions, in which
the use of drugs is frequently condemned. In following a religion, a set of
values and behavioral patterns is adhered to, among which a prohibition on the
use of drugs is included.

The question
of family structure is traditionally emphasized when studying the use of drugs
among adolescents. In the present study, the importance of the family environment
and structure was identified as a possible protective factor against the use
of drugs. Less heavy use of drugs was found among students who in some way felt
they were supported and understood by their families.

Several
authors have identified risky levels of drug use among young people belonging
to families with separated parents or families in which the relationships have
degenerated.8 Thus, the present study corroborates previous research
that identified an association between the use of drugs at risky levels and
worsened family environments.

Finally,
it was seen that increased scores on the GHQ-12 scale were associated with a
risk of heavy use of drugs. These data are relevant, since they show a relationship
between heavy use of drugs and psychological suffering. These young people have
probably found themselves in a situation of serious psychosocial risk, since
such clusters of psychological suffering, worsened family environment and heavy
use of drugs must facilitate evolution towards chemical dependence, personality
disorders and even psychiatric conditions that are more serious.

In conclusion,
the present study has identified that the heavy use of drugs is related to sociodemographic,
cultural and psychopathological factors that can be grouped as "protectors"
and "facilitators". The protective factor identified was a markedly religious
education during childhood, which perhaps indicates a more controlled or structured
family environment. The facilitating factors for heavy use of legal and illegal
drugs that were identified were greater financial wherewithal (socioeconomic
class and work), socialization patterns that shape adult-style behavior (work
and evening study) and a possibly worsened family environment (feeling less
supported and understood by the family). The empirical findings reported have
helped in reaching a better comprehension regarding the heavy use of drugs among
young people in Brazil's sociocultural environment, and these findings should
be taken into account in future research and educational and preventive interventions.

Received
on 6/11/2002
Reviewed on 19/8/2003
Approved on 19/9/2003Research
funded by Fundação de Amparo à Pesquisa do Estado de São
Paulo (Fapesp  Process n. 00/02082-4).

Work developed
in the Department of Medical Psychology and Psychiatry of the School of Medical
Sciences of Universidade Estadual de Campinas.Article
based on doctoral thesis presented to Universidade Estadual de Campinas, 2001.